Background <p>Intravenous sedation (IVS) is widely used in office-based esthetic surgery, yet large-scale safety data from private clinics are scarce. This study quantified IVS utilization and evaluated perioperative safety in a high-volume Japanese cosmetic center.</p> Methods <p>A retrospective review was conducted of all consecutive procedures performed under IVS between November 2020 and December 2024 at a single clinic. Eligibility was restricted to American Society of Anesthesiologists (ASA) class I–II patients. Propofol was the first-line sedative; midazolam was substituted for documented egg or soy allergy. Standard monitoring (ECG, noninvasive blood pressure, SpO₂ alarm at 90 %) and a target Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) score of 2–3 were employed. Primary endpoints were major cardiopulmonary events (unplanned intubation, cardiac arrest). Secondary endpoints comprised intra-operative antihypertensive therapy, elective termination of sedation owing to paradoxical agitation, prolonged recovery (&gt; 30&#xa0;min to discharge readiness), and unplanned admission</p> Results <p>A total of 4,397 IVS procedures were analyzed (female 89.7%, median age 39 years). Annual case volume rose from 41 (2020) to 1,753 (2024); combined procedures increased from 6.5 to 86.5 % over the same period. Propofol was used in 4,366 cases (99.3%); midazolam was administered in 31 allergy-screened cases (0.7%). No major cardiopulmonary events occurred (0%; 95% CI 0.00–0.08). Hypertensive episodes treated with intravenous nicardipine were observed in 44 cases (1.0%); no patient required supplemental oxygen. Sedation was electively discontinued for paradoxical agitation in 24 cases (0.55%). Prolonged recovery was recorded in 75 cases (1.7%); all patients were discharged on the same day. No unplanned admissions occurred.</p> Conclusions <p>Among 4,397 office-based esthetic procedures, IVS directed by non-anesthesiologist surgeons achieved a major complication rate of zero and a low incidence of minor events. Strict ASA I–II selection, continuous physiologic monitoring, and a weight-adjusted depth titration protocol can provide international-level safety in a private outpatient setting. Multicenter prospective studies are warranted to validate these findings and refine recovery benchmarks.</p> Level of Evidence IV <p>This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors <a href="http://www.springer.com/00266">www.springer.com/00266</a>.</p>